National Care Service - national systems of social care in Nordic and Scandinavian countries: learning and evidence review

Summary of findings

What we did

We undertook a rapid scoping review to identify the key learning, barriers and facilitators from national systems of integrated health and social care from the Nordic and Scandinavian countries. This also included pan-European studies if they included one or more Nordic or Scandinavian countries. We searched six databases of peer-reviewed literature, and the grey literature,^[4] with key search terms from 2010 until January 2022. The key learning from the included research reports was identified and captured under three main research questions: learning from service users, learning from key informants, and the impact of social care at a population health level. Due to the rapid nature of this review, we have not critically appraised the research studies, and present their findings as reported by the study authors rather than as the views of Public Health Scotland.

What we found

Although national social care systems varied between Nordic and Scandinavian countries, the included studies did not identify any specific national "model" of integrated social care in the countries studied. Social care tended to be delivered in a country specific context, which mainly resulted from integration of organisations and services including how they were governed and funded. How services were controlled (e.g. centrally or locally) and delivered over time, also varied depending on the welfare regime and political views at a given time.

User experience

A number of studies highlighted the importance of relationships between users of care services, professionals and unpaid carers. This helped to ensure users' needs were being met and that their preferences were being taken into account, as well as facilitating alignment of different parts of the system. There was evidence on the impact of inequalities in systems in terms of access and quality, in particular, for service users with complex needs.

Learning from other key informants

Governance

The evidence reviewed suggests the following principles should be incorporated into governance systems: a clear vision for integrated care and underpinning legislation that is supportive and consistent; only enshrine in law critical elements while leaving room for local flexibility depending on context; the balance of centralisation and decentralisation is less important than being clear about roles and responsibilities and level of funding; and that monitoring systems should include user and process outcomes.

Funding

Key informant evidence on the effect on cost, health and service use outcomes is mixed and approaches to achieve integrated funding are variable across the Scandinavian and Nordic countries. Key facilitators of financial integration include a shared vision among stakeholders, unified structures, coordinated funding and consideration of local circumstances. Difficulties of implementing financial integration were common, with a specific challenge being different payment structures or separate budgets and the transfer of funds between different parts of the system.

Marketisation in the provision of health and social care is increasingly common and approaches varied across countries. While it offers increased choice for care users and could potentially improve quality of care due to competition between providers, it challenges universalism, integrated care provision and equality of access.

User involvement

Professionals in health and social care see collaboration with users as key for service delivery. However, the practicalities, time, service provision and administrative processes can be barriers especially in developing individual care plans.

Learning from key informant studies emphasised the importance of safeguarding systems across all levels of staff and service providers to ensure vulnerable users are protected and treated appropriately across the care system.

Key informants identified cooperation and trust between different parts of the system and service providers as important. This included the sharing of resources and responsibilities to deliver quality services for different target populations. This went beyond just health and social care integration and could include other sectors such as education and employment. Shared information and communication systems were also viewed as promoting integration, as well as improving service quality and workforce development.

Where people can safely access care is an important factor in meeting the needs of users. Provision of home-based care in addition to formal care settings needs to be considered.

Workforce

A commitment to provide continuous professional development, training and good work conditions with a degree of autonomy across the social care workforce, should be considered in providing efficient social care services.

Population health outcomes

Much of the population health outcomes evidence identified for social care^[5] draws from studies using the Survey of Health Ageing and Retirement in Europe (SHARE). Findings from SHARE studies included inequalities in access to care and unmet need within and across European countries, particularly between users with different socio-economic positions; and the consequences of out-of-pocket costs, which were more likely to affect the poorest and most vulnerable older people. There were several other studies considering the relationship between integrated programmes and demand in other parts of the health system such as emergency department admissions. The results were mixed as to whether integrated health and social care resulted in lower demand for services elsewhere in health care.

What this report does not tell us

This rapid scoping review was not designed to provide a systematic, quality-assessed synthesis of evidence. It does not provide a comprehensive analysis of "what works", but rather provides learning on national social care systems from Nordic and Scandinavian countries. Due to the rapid nature of this review, we have not critically appraised the research studies, and the report does not include recommendations but reports findings as published in the included studies rather than as the views of Public Health Scotland. Our review does not include children's services and does not look at community and local programmes of social care services.

The report does not include any detailed analysis of the current health and social care system structures in the included countries. However, further details can be found in the European Social Policy Network's thematic reports on the long-term challenges of social care across European countries (2018).

We did not attempt to look at definitions in terms of consistency of language and meaning across the countries included in this report, and have adopted terms commonly used in Scotland rather than broadly equivalent terms in other countries (e.g. social care rather than long-term care, or unpaid care rather than informal care). However, a glossary of terms used across social care in Europe and other countries is available from the OECD 2011 report "Help Wanted?".

Neither did we find any mention of third sector organisations involved in delivery of care services in Nordic and Scandinavian countries. This may in part be due to how social care is funded and delivered by the public and private sectors in each of the countries.

Implications for policy and research

No single national "model" of social care was identified, and no consensus was found on optimal governance or funding arrangements. However, the evidence does highlight general key principles that can act as enablers or barriers to the creation of a national social care service depending on national context.

Although we found a large number of studies eligible for inclusion in this review, much of the evidence was largely descriptive. There was little evidence of robust programme evaluations of national social care systems in Nordic or Scandinavian countries.